IntroductionMany primary care practices do not have a well-organized system for changing how clinical care and screening are delivered. In addition, practices often do not have the internal resources to follow up on positive depression screens. Thus, there is a role for either the practice's parent organization or an outside organization or agency, such as a practice network or public health department, to assist primary care practices in designing and implementing parental depression screening.

Provision of Referral and Treatment ServicesIn many communities, it is necessary to bring together several organizations to provide parental depression screening and treatment.

Figure 5 is a worksheet that summarizes the steps needed to prepare to implement community-wide or statewide screening. These steps are described in more detail below. A copy of the worksheet is found in the appendices.

Figure 5: Prepare Your Community (Click image to open at full size.)

Engage Your Partners

Identify Champions

A senior executive who wishes to implement a community-wide screening effort needs to champion the program within their institution. This person then recruits others at a similar level at other key organizations or agencies that have a stake in parental depression screening. This small group leads a process to develop the screening. As many representatives of the process as possible should be included, from adult and pediatric primary care clinicians to mental health providers and insurance companies.

Motivate/Educate Partners

The impact of parental depression on the health and well-being of their children may not be well understood. An important part of implementing screening is to dispel any stigma or myths about depression and to help potential partner organizations understand that identifying and treating parental depression will benefit their institution and community.

Develop a Community Approach

Explore Available Resources and Network with Collaborators

Once you have decided what group of practices you will work with to implement screening, it is important to determine the mental health services and providers available to help practices assess, diagnose, and treat depression. These may be local or state-level resources that are private or public. These partners will need to help others understand that helping the parent get timely services benefits both the parent and child.

Establish Triage/Referral Mechanism

Simply identifying resources will not ensure that depressed parents identified by their child's clinician will seek and receive assessment and a diagnosis of depression. The Parent Support Line, however, is an example of a system that reaches out to depressed parents, assesses their symptoms, and refers them to appropriate care and services.

Parent Support Line

The Parent Support Line (PSL) of the Parental Well-Being Project utilized the resources of a behavioral health employee assistance triage team for parents who were referred by participating practices. The triage team had licensed M.S.W. staff. Their assessments began with the chief complaint/or initial request. Within that context, triage was conducted to determine the level of functioning, particularly neuro-vegetative signs of mood disorders. Particular attention was paid to risk factors such as substance issues, violence, and suicidal/homicidal ideation. Triage explored psychosocial stressors in the work, home, and social environment, paying close attention to support systems in place or needed. Special attention was paid to how well the caller thought they were parenting while experiencing depression or stress. Triage might include one or all of the following: assessment or brief treatment by a licensed independent master's level clinician, referral to community resources, and information and resources that may be helpful in educating or informing the parent about how to cope or solve their various issues. Follow-up calls to the parent were made to ensure a satisfactory outcome.

A centralized approach—using an institutional- or community-based social worker or practice-level care manager—is another way to ensure that there is follow-up and assistance in getting treatment and support for parents who screen at risk for depression.

Recruit and Train Primary CareOrganizations such as insurance companies, health agencies, hospitals, or groups of practices that want to support parental depression screening at multiple practices can do the following:

Increase awareness of clinicians about the impact of parental depression.

Many clinicians are unaware of the continuing impact of parental depression on children throughout childhood. Including this topic in local pediatric conferences can help create an environment where clinicians will consider changing their behavior. Only 57 percent of pediatricians who participated in a national survey considered it their responsibility to recognize maternal depression.

Provide materials to clinicians needed to implement screening in their practice.

Screening tools, posters, and parental handouts are all helpful for practices to implement screening, though few clinicians will start screening because they received educational materials. In the Parental Depression Project, 13 additional regional practices were provided with detailed educational materials and an implementation guide. Follow-up after six months showed that no practice had implemented routine screening at well-child visits. Due to competing demands, a systematic effort is needed.

Assist practices in changing their office system to support screening and referral.

A number of approaches have been used within the clinical quality improvement field to change the process of ambulatory care. For example, a team approach offers clearly defined roles and responsibilities for different staff, tools, and mechanisms to monitor the success of the implementation (see Section 3). This has been done by providing on-site consultation to the practice team and by bringing several practice teams together in a "learning collaborative." Both of these approaches entail follow-up in person or by phone conference to keep the process going. Although time-consuming, the learning collaborative has the advantage of sharing solutions between practices.

There are several ways the external organization can support the continuation of screening programs in pediatric care practices. One is by periodically reviewing the screening and referral process and assessing the satisfaction of both the parents and the providers. Also, the external organization can educate and help to de-stigmatize depression through informational articles in local papers or local parent meetings. Information for new providers who join the mental health and primary care communities can help continuation of a broad approach. Periodic phone conferences or meetings between practice champions can offer an avenue for support and problem-solving.

Comments from Project Leader

"It was very helpful for clinicians to share their approaches to discussing maternal depression and how they addressed the issues resulting with the child. These shared discussions usually led to descriptions of instances where the parent was very appreciative of this approach to depression and reinforced their efforts."

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The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.